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Question 1Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which antiemetic regimen is standard prophylaxis for a patient receiving highly emetogenic cisplatin-based chemotherapy?

  1. Olanzapine plus dexamethasone only
  2. A 5-HT3 antagonist given alone at the time of infusion
  3. A 5-HT3 antagonist, dexamethasone, and an NK1 receptor antagonist Correct answer.
  4. Metoclopramide plus diphenhydramine and lorazepam

Explanation

Highly emetogenic regimens such as cisplatin require three-drug prophylaxis combining a 5-HT3 antagonist, dexamethasone, and an NK1 receptor antagonist, with olanzapine often added. This combination targets multiple emetic pathways and is recommended from the first cycle.

Question 2Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with a solid tumor develops a temperature of 38.5°C and an absolute neutrophil count of 400 cells/mm3 on day 10 after chemotherapy. Which empiric antimicrobial regimen is most appropriate?

  1. Vancomycin plus metronidazole
  2. Trimethoprim-sulfamethoxazole
  3. Oral levofloxacin managed as an outpatient
  4. Cefepime monotherapy Correct answer.

Explanation

Febrile neutropenia requires prompt empiric coverage with an antipseudomonal beta-lactam such as cefepime, piperacillin-tazobactam, or meropenem. Additional agents are added only for specific indications such as suspected gram-positive infection or hemodynamic instability.

Question 3Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

In a high-dose methotrexate regimen with leucovorin rescue, when should the first leucovorin dose be given?

  1. Twenty-four hours after the start of the methotrexate infusion Correct answer.
  2. At the same time the methotrexate infusion begins
  3. Twelve hours before the methotrexate infusion
  4. Only after the serum methotrexate concentration exceeds 10 micromolar

Explanation

Leucovorin rescue is scheduled to begin 24 hours after the start of the methotrexate infusion, when methotrexate levels are declining. Giving it earlier can rescue tumor cells, while waiting for a threshold level delays protection of normal tissues.

Question 4Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which agent is administered with ifosfamide to prevent hemorrhagic cystitis?

  1. Leucovorin
  2. Dexrazoxane
  3. Amifostine
  4. Mesna Correct answer.

Explanation

Ifosfamide generates acrolein, a urotoxic metabolite that causes hemorrhagic cystitis. Mesna is excreted renally and inactivates acrolein in the bladder, so it is given with each ifosfamide dose.

Question 5Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which cumulative doxorubicin dose is generally considered the threshold for increased cardiomyopathy risk in a patient without other cardiac risk factors?

  1. 550 mg/m2 Correct answer.
  2. 1200 mg/m2
  3. 300 mg/m2
  4. 850 mg/m2

Explanation

Anthracycline cardiotoxicity is cumulative and dose dependent, with a widely used threshold of approximately 550 mg/m2 for doxorubicin in patients without additional risk factors. Risk rises sharply above this level, and lower thresholds apply with mediastinal radiation or preexisting cardiac disease.

Question 6Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

What maximum single intravenous dose of vincristine is conventionally used in adult regimens to limit neurotoxicity?

  1. 6 mg
  2. 2 mg Correct answer.
  3. 1 mg
  4. 4 mg

Explanation

Vincristine neurotoxicity is dose related, and a maximum single dose of 2 mg is conventionally used in most adult regimens. Exceeding this cap increases the risk of severe peripheral and autonomic neuropathy without a clear added benefit.

Question 7Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Primary prophylaxis with a granulocyte colony-stimulating factor is recommended when a chemotherapy regimen carries a risk of febrile neutropenia of at least what percentage?

  1. 50%
  2. 5%
  3. 10%
  4. 20% Correct answer.

Explanation

Guidelines recommend routine primary G-CSF prophylaxis when the baseline risk of febrile neutropenia is approximately 20% or higher. Lower thresholds may apply when patient-specific risk factors add to the regimen's intrinsic risk.

Question 8Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Rasburicase is contraindicated in patients with which condition because of the risk of severe hemolysis?

  1. Prior allopurinol intolerance
  2. Glucose-6-phosphate dehydrogenase deficiency Correct answer.
  3. Hyperuricemia above 10 mg/dL
  4. Chronic kidney disease

Explanation

Rasburicase generates hydrogen peroxide during urate oxidation, which can cause oxidative hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency. Screening is required before use in higher-risk populations.

Question 9Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient has a measured glomerular filtration rate of 60 mL/min and is prescribed carboplatin targeting an AUC of 6 mg·min/mL. What dose does the Calvert formula yield?

  1. 600 mg
  2. 425 mg
  3. 510 mg Correct answer.
  4. 360 mg

Explanation

The Calvert formula is total dose (mg) = target AUC × (GFR + 25). Using AUC 6 and GFR 60 gives 6 × 85, or 510 mg.

Question 10Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with colorectal cancer who is maintained on warfarin is starting capecitabine. Which monitoring step is essential?

  1. Frequent INR checks with warfarin dose adjustment Correct answer.
  2. Checking the serum creatinine twice weekly
  3. Daily complete blood counts during the first cycle
  4. Routine electrocardiograms before each cycle

Explanation

Capecitabine inhibits CYP2C9 and can markedly potentiate warfarin, raising the INR and bleeding risk. Close INR monitoring with proactive warfarin dose reduction is required when therapy starts or the dose changes.

Question 11Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A woman taking tamoxifen for hormone receptor-positive breast cancer needs an antidepressant. Which agent best avoids reducing tamoxifen activation?

  1. Paroxetine
  2. Bupropion
  3. Venlafaxine Correct answer.
  4. Fluoxetine

Explanation

Tamoxifen requires CYP2D6-mediated conversion to endoxifen, so strong CYP2D6 inhibitors such as paroxetine and fluoxetine are avoided. Venlafaxine is a weak CYP2D6 inhibitor and is generally preferred in this setting.

Question 12Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving high-dose methotrexate has a serum methotrexate concentration of 50 micromolar at 48 hours with a rising serum creatinine. Which intervention is most appropriate?

  1. Restart high-dose methotrexate at a reduced dose
  2. Continue the current leucovorin dose and recheck the level in 24 hours
  3. Give folinic acid only after hemodialysis is arranged
  4. Administer glucarpidase and continue leucovorin Correct answer.

Explanation

Delayed methotrexate elimination with nephrotoxicity and a high 48-hour level is an indication for glucarpidase, which rapidly hydrolyzes extracellular methotrexate. Leucovorin must be continued after glucarpidase because the enzyme does not protect intracellular sites.

Question 13Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

During trastuzumab therapy, the drug should be withheld when left ventricular ejection fraction falls by how much from baseline?

  1. Any decrease of 5% from baseline
  2. An absolute decrease of 16% or more Correct answer.
  3. Only when ejection fraction falls below 60%
  4. A decrease of 8% or more from baseline

Explanation

Trastuzumab is held for an absolute decline in left ventricular ejection fraction of at least 16% from baseline, or a decline of at least 10% to a value below the institutional lower limit of normal. Ejection fraction is reassessed about every 3 months during therapy.

Question 14Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which premedication is standard before the first rituximab infusion?

  1. Dexamethasone and ondansetron
  2. Allopurinol and sodium bicarbonate
  3. Morphine and lorazepam
  4. Acetaminophen and diphenhydramine Correct answer.

Explanation

Rituximab commonly causes infusion-related reactions mediated by cytokine release, so acetaminophen and an antihistamine such as diphenhydramine are given before the first infusion. The first infusion is also started slowly and escalated as tolerated.

Question 15Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Bevacizumab should be withheld at least how long before elective surgery?

  1. 4 weeks Correct answer.
  2. 2 weeks
  3. 12 weeks
  4. 7 days

Explanation

Bevacizumab impairs wound healing through VEGF inhibition, so it is generally held for at least 4 weeks before elective surgery and not restarted until the surgical incision is fully healed.

Question 16Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which effect is expected when ketoconazole is coadministered with imatinib?

  1. No change in imatinib exposure
  2. Decreased imatinib and increased ketoconazole concentrations
  3. Increased imatinib plasma concentrations Correct answer.
  4. Decreased imatinib plasma concentrations

Explanation

Imatinib is metabolized primarily by CYP3A4, and ketoconazole is a strong CYP3A4 inhibitor. Coadministration raises imatinib exposure and the risk of toxicity, so alternative antifungals or dose reduction are considered.

Question 17Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving bortezomib develops grade 2 painful peripheral neuropathy. What is the most appropriate management?

  1. Hold bortezomib until symptoms resolve, then restart at a reduced dose Correct answer.
  2. Double the dose to overcome resistance
  3. Switch from subcutaneous to intravenous administration
  4. Continue the same dose and add gabapentin

Explanation

Bortezomib causes a dose-related, often painful peripheral neuropathy. Grade 2 neuropathy with pain is managed by holding therapy until improvement and then resuming at a reduced dose, with subcutaneous administration used to lower risk.

Question 18Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient starting lenalidomide with low-dose dexamethasone for multiple myeloma is assessed as having low venous thromboembolism risk. Which prophylaxis is appropriate?

  1. Warfarin titrated to an INR goal of 2 to 3
  2. Aspirin 81 to 325 mg daily Correct answer.
  3. No prophylaxis is needed
  4. Prophylactic inferior vena cava filter placement

Explanation

Immunomodulatory drugs such as lenalidomide increase venous thromboembolism risk, and prophylaxis is required for essentially all patients. Low-risk patients typically receive aspirin, while higher-risk patients receive low-molecular-weight heparin or adjusted-dose warfarin.

Question 19Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

During a high-dose methotrexate infusion, urine pH should be maintained at or above which value?

  1. 5.0
  2. 6.0
  3. 7.0 Correct answer.
  4. 8.5

Explanation

Methotrexate and its metabolite precipitate in acidic urine, so urine pH is alkalinized to 7.0 or higher with intravenous fluids and sodium bicarbonate. Adequate urine output is maintained at the same time to limit tubular precipitation.

Question 20Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with partial dihydropyrimidine dehydrogenase deficiency receives a standard dose of fluorouracil. What outcome is expected?

  1. Reduced antitumor effect only
  2. Increased renal clearance of fluorouracil
  3. No effect on toxicity profile
  4. Severe toxicity such as mucositis and myelosuppression Correct answer.

Explanation

Dihydropyrimidine dehydrogenase is the main enzyme that degrades fluorouracil, so partial deficiency markedly prolongs drug exposure. Affected patients develop severe mucositis, myelosuppression, and diarrhea at standard doses and require substantial dose reduction or alternative therapy.

Question 21Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which patient is the best candidate for rasburicase rather than allopurinol for tumor lysis prophylaxis?

  1. A patient with breast cancer receiving adjuvant chemotherapy
  2. A patient with chronic lymphocytic leukemia and a normal uric acid level
  3. A patient with Burkitt lymphoma and a high baseline uric acid level Correct answer.
  4. A patient with a solid tumor and mild hyperuricemia

Explanation

Rasburicase is preferred for patients at high risk of tumor lysis, such as those with Burkitt lymphoma, high tumor burden, or elevated baseline uric acid. Allopurinol is adequate for low-risk patients because it prevents new uric acid formation but does not degrade existing uric acid.

Question 22Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with a baseline QTc of 480 ms is prescribed ondansetron for chemotherapy-induced nausea. Which action is most appropriate?

  1. Consider an alternative antiemetic and correct electrolyte abnormalities Correct answer.
  2. Administer ondansetron only after premedicating with haloperidol
  3. Give the standard dose and repeat an electrocardiogram in 3 months
  4. Add a second 5-HT3 antagonist for synergistic antiemetic effect

Explanation

Ondansetron prolongs the QT interval in a dose-dependent manner, so a baseline QTc above 450 to 470 ms warrants caution. Correcting potassium and magnesium and selecting an alternative antiemetic reduce the risk of torsades de pointes.

Question 23Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with the UGT1A1*28/*28 genotype is beginning an irinotecan-containing regimen. Which toxicity is most increased?

  1. Severe diarrhea
  2. Peripheral neuropathy
  3. Severe neutropenia Correct answer.
  4. Hepatic veno-occlusive disease

Explanation

UGT1A1 glucuronidates the active irinotecan metabolite SN-38, and homozygous *28 carriers have reduced glucuronidation. This raises SN-38 exposure and markedly increases the risk of severe neutropenia, which may prompt a lower starting dose or closer monitoring.

Question 24Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

What is the main purpose of adding dexrazoxane to an anthracycline regimen in a patient approaching high cumulative doxorubicin exposure?

  1. Prevention of nausea and vomiting
  2. Prevention of tumor lysis syndrome
  3. Enhancement of antitumor activity
  4. Reduction of anthracycline-related cardiotoxicity Correct answer.

Explanation

Dexrazoxane is an iron chelator that reduces anthracycline-mediated free radical injury to cardiac myocytes. It is used when cumulative anthracycline exposure is high and continued anthracycline therapy is still required.

Question 25Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient develops confusion and somnolence during an ifosfamide infusion. Which treatment is most appropriate?

  1. Naloxone
  2. Methylene blue Correct answer.
  3. Dexrazoxane
  4. Flumazenil

Explanation

Ifosfamide can cause a metabolic encephalopathy related to the metabolite chloroacetaldehyde, manifested by confusion, somnolence, and occasionally seizures. Intravenous methylene blue is the standard treatment and typically produces rapid improvement.

Question 26Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with a solid tumor develops a temperature of 38.6°C and an absolute neutrophil count of 350 cells/mm³ ten days after chemotherapy. Which initial empiric therapy is most appropriate?

  1. Observation with a repeat CBC in 48 hours
  2. Oral fluconazole
  3. Intravenous cefepime Correct answer.
  4. Intravenous acyclovir

Explanation

Febrile neutropenia requires prompt empiric broad-spectrum antibacterial therapy covering Pseudomonas aeruginosa. Antifungal or antiviral agents are not used routinely as initial monotherapy in this setting.

Question 27Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient is beginning pemetrexed for malignant pleural mesothelioma. Which supportive measure is required to reduce hematologic and gastrointestinal toxicity?

  1. Iron and erythropoietin
  2. Magnesium oxide and potassium chloride
  3. Vitamin K and calcium gluconate
  4. Folic acid and vitamin B12 Correct answer.

Explanation

Pemetrexed is a multitargeted antifolate, and supplementation with folic acid and vitamin B12 reduces severe hematologic and gastrointestinal toxicity. Dexamethasone is also used to reduce rash.

Question 28Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving cetuximab for metastatic colorectal cancer has routine laboratory monitoring. Which electrolyte abnormality is most characteristic of EGFR inhibitor therapy?

  1. Hyperkalemia
  2. Hypomagnesemia Correct answer.
  3. Hypercalcemia
  4. Hypernatremia

Explanation

EGFR inhibitors such as cetuximab can cause renal magnesium wasting and hypomagnesemia. Magnesium should be monitored and replaced as needed.

Question 29Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with high-risk lymphoma is starting allopurinol before chemotherapy for tumor lysis prophylaxis. Allopurinol lowers uric acid production by inhibiting which enzyme?

  1. Xanthine oxidase Correct answer.
  2. Topoisomerase II
  3. Thymidylate synthase
  4. Dihydrofolate reductase

Explanation

Allopurinol inhibits xanthine oxidase, blocking conversion of hypoxanthine and xanthine to uric acid. It prevents new uric acid formation but does not rapidly clear existing uric acid.

Question 30Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which antiemetic regimen is preferred for prevention of acute nausea and vomiting from highly emetogenic cisplatin-based chemotherapy?

  1. A dopamine antagonist and diphenhydramine
  2. An NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone Correct answer.
  3. Dexamethasone and metoclopramide only
  4. A 5-HT3 receptor antagonist and lorazepam only

Explanation

Highly emetogenic chemotherapy requires guideline-based combination prophylaxis, typically an NK1 receptor antagonist plus a 5-HT3 receptor antagonist plus dexamethasone. Olanzapine may be added for further control.

Question 31Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

After high-dose methotrexate, leucovorin is given to rescue normal cells. Leucovorin bypasses the methotrexate-induced blockade of which enzyme?

  1. Topoisomerase I
  2. Dihydrofolate reductase Correct answer.
  3. Ribonucleotide reductase
  4. Thymidine phosphorylase

Explanation

Methotrexate inhibits dihydrofolate reductase, depleting reduced folate pools. Leucovorin is a reduced folate that replenishes these pools and bypasses the enzymatic blockade in normal cells.

Question 32Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with acute lymphoblastic leukemia has low thiopurine methyltransferase activity before starting 6-mercaptopurine. Which dose adjustment is most appropriate?

  1. Reduce the dose substantially Correct answer.
  2. Use the standard dose without change
  3. Replace 6-mercaptopurine with methotrexate
  4. Increase the dose to improve efficacy

Explanation

Low thiopurine methyltransferase activity shunts 6-mercaptopurine toward active thioguanine nucleotides, increasing myelosuppression. Patients require substantial dose reduction or an alternative thiopurine strategy based on genotype and protocol guidance.

Question 33Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient develops grade 3 cytokine release syndrome with hypotension requiring vasopressors after chimeric antigen receptor T-cell therapy. Which agent is first-line treatment?

  1. Siltuximab
  2. Dexamethasone
  3. Infliximab
  4. Tocilizumab Correct answer.

Explanation

Tocilizumab, an interleukin-6 receptor antagonist, is first-line therapy for grade 2 or higher cytokine release syndrome after CAR T-cell therapy. Corticosteroids may be added for grade 3 or higher or for inadequate response.

Question 34Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with chronic lymphocytic leukemia at high risk for tumor lysis syndrome is starting venetoclax. Which monitoring approach is required during the dose ramp-up?

  1. Avoid laboratory monitoring unless symptoms develop
  2. Check a complete blood count weekly only
  3. Check electrolytes and creatinine before and after dose escalation, with hydration and uric acid control Correct answer.
  4. Check the INR daily

Explanation

Venetoclax ramp-up can cause rapid tumor lysis, especially in high-risk patients. Electrolytes, creatinine, and uric acid must be monitored closely around dose escalation, with adequate hydration and anti-hyperuricemic prophylaxis.

Question 35Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving immune checkpoint inhibitor therapy develops grade 2 immune-mediated colitis with diarrhea. Which management is most appropriate initially?

  1. Continue therapy and use loperamide only
  2. Start empirical antibiotics
  3. Hold immunotherapy and start corticosteroid therapy Correct answer.
  4. Start infliximab immediately

Explanation

Grade 2 immune-mediated colitis generally warrants holding checkpoint inhibitor therapy and starting systemic corticosteroids. Infliximab is reserved for steroid-refractory or higher-grade colitis.

Question 36Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which monitoring is most appropriate for a patient receiving bleomycin as part of lymphoma therapy?

  1. Serum amylase before every cycle
  2. Chest imaging and pulmonary function assessment Correct answer.
  3. Echocardiography before every cycle
  4. Liver biopsy after cumulative dose reaches 100 units

Explanation

Bleomycin can cause cumulative dose-related pulmonary toxicity. Monitoring should include pulmonary symptoms, chest imaging, and pulmonary function testing when appropriate.

Question 37Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving pegaspargase develops urticaria and bronchospasm during the infusion. Which action is most appropriate?

  1. Stop the infusion, treat anaphylaxis, and consider Erwinia asparaginase for future doses Correct answer.
  2. Give atropine and resume at the same rate
  3. Continue the infusion and premedicate before the next dose only
  4. Slow the infusion and give an oral antihistamine

Explanation

Urticaria with bronchospasm during pegaspargase indicates a hypersensitivity reaction and requires immediate discontinuation and treatment of anaphylaxis. Subsequent asparaginase therapy may use an Erwinia-derived product because of cross-reactivity concerns with pegaspargase.

Question 38Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which premedication is required before intravenous temsirolimus to reduce the risk of hypersensitivity reactions?

  1. Leucovorin
  2. Mesna
  3. Vitamin B12 and folic acid
  4. An antihistamine Correct answer.

Explanation

Intravenous temsirolimus requires antihistamine premedication before each dose to reduce hypersensitivity reactions. Additional premedication may be needed for patients who have had prior reactions.

Question 39Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with acute promyelocytic leukemia receiving arsenic trioxide develops fever, dyspnea, weight gain, and pulmonary infiltrates. Which complication is most likely?

  1. Contrast-induced nephropathy
  2. Differentiation syndrome Correct answer.
  3. Pulmonary embolism
  4. Tumor lysis syndrome

Explanation

Arsenic trioxide can trigger differentiation syndrome, characterized by fever, dyspnea, weight gain, hypotension, and pulmonary infiltrates. Treatment includes holding arsenic trioxide and giving corticosteroids.

Question 40Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient stabilized on ibrutinib for mantle cell lymphoma now requires voriconazole for invasive fungal infection. Which management is most appropriate?

  1. Switch the patient to rifampin
  2. Reduce the ibrutinib dose or avoid the strong CYP3A inhibitor Correct answer.
  3. No change to the ibrutinib dose
  4. Increase the ibrutinib dose

Explanation

Voriconazole is a strong CYP3A inhibitor and markedly increases ibrutinib exposure, raising toxicity risk. The ibrutinib dose should be reduced according to labeling or the interacting drug avoided if possible.

Question 41Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving high-dose cytarabine develops nystagmus and ataxia. Which action is most appropriate?

  1. Hold cytarabine and perform a neurologic evaluation Correct answer.
  2. Continue the infusion and observe
  3. Give dexamethasone and continue cytarabine
  4. Give leucovorin

Explanation

Nystagmus and ataxia during high-dose cytarabine suggest cerebellar toxicity. Cytarabine should be held and the patient evaluated promptly because continued dosing can worsen neurologic injury.

Question 42Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient taking sunitinib for renal cell carcinoma has a blood pressure of 160/100 mmHg. Which management is most appropriate?

  1. Reduce the sunitinib dose only if hypertension becomes severe
  2. Discontinue sunitinib permanently
  3. Start antihypertensive therapy and continue blood pressure monitoring Correct answer.
  4. Give a diuretic alone without monitoring

Explanation

Hypertension is a common vascular endothelial growth factor pathway inhibitor toxicity. It should be treated with antihypertensive therapy while monitoring blood pressure and modifying the sunitinib dose for severe or uncontrolled hypertension.

Question 43Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which preventive measure is recommended to reduce the incidence and severity of everolimus-associated stomatitis?

  1. Saline rinses only
  2. Dexamethasone mouthwash Correct answer.
  3. Antiviral prophylaxis
  4. Prophylactic broad-spectrum antibiotics

Explanation

Dexamethasone mouthwash used prophylactically decreases the incidence and severity of everolimus-associated stomatitis. Good oral hygiene and prompt management of lesions are also important.

Question 44Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Which monitoring is essential before and during nilotinib therapy for chronic myeloid leukemia?

  1. Serum amylase measurement
  2. Electrocardiography for QTc interval Correct answer.
  3. Thyroid function testing
  4. Urine pH measurement

Explanation

Nilotinib can prolong the QTc interval, so electrocardiography and electrolyte monitoring are recommended before and during therapy. Drugs that also prolong QTc should be avoided when possible.

Question 45Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient with chronic myeloid leukemia on dasatinib develops dyspnea and a new pleural effusion. Which management is most appropriate?

  1. Hold dasatinib and consider corticosteroids and supportive care Correct answer.
  2. Give antibiotics and continue the same dose
  3. Increase the dasatinib dose
  4. Start diuretics and continue dasatinib unchanged

Explanation

Pleural effusion is a recognized dasatinib toxicity. Management includes withholding dasatinib, supportive care, and corticosteroids or diuretics depending on severity, with dose reduction or discontinuation for recurrent cases.

Question 46Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient taking sorafenib for hepatocellular carcinoma develops painful erythema and desquamation of the palms and soles. Which initial management is most appropriate?

  1. Empiric antibiotics for cellulitis
  2. Application of heat to the affected areas
  3. Permanent discontinuation of sorafenib
  4. Supportive skin care with emollients and padding, with dose modification if severe Correct answer.

Explanation

Sorafenib commonly causes hand-foot skin reaction. Initial management includes emollients, padding, avoidance of friction, and dose modification or interruption for severe symptoms.

Question 47Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving blinatumomab develops confusion and a tremor. Which action is most appropriate?

  1. Continue the infusion and observe
  2. Hold blinatumomab and evaluate neurologic status, with corticosteroid consideration Correct answer.
  3. Give filgrastim
  4. Give lorazepam only and continue blinatumomab

Explanation

Blinatumomab can cause serious neurologic toxicity, including confusion, tremor, seizures, and encephalopathy. The infusion should be held and the patient evaluated, with corticosteroids considered according to severity and protocol guidance.

Question 48Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

Mesna is administered with ifosfamide to prevent which complication?

  1. Hemorrhagic cystitis Correct answer.
  2. Peripheral neuropathy
  3. Cardiomyopathy
  4. Pulmonary fibrosis

Explanation

Mesna binds acrolein, a urotoxic metabolite of ifosfamide and cyclophosphamide, in the urine. This reduces the risk of hemorrhagic cystitis.

Question 49Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient receiving trastuzumab deruxtecan develops cough and dyspnea, and imaging shows interstitial lung disease. Which management is most appropriate?

  1. Continue therapy and start antibiotics
  2. Start high-dose corticosteroids only after further progression
  3. Increase the trastuzumab deruxtecan dose
  4. Hold trastuzumab deruxtecan and start corticosteroid therapy Correct answer.

Explanation

Trastuzumab deruxtecan can cause interstitial lung disease or pneumonitis, which may be severe. Therapy should be held or discontinued according to grade, and corticosteroids should be initiated promptly.

Question 50Design, implementation, monitoring, and modification of pharmacotherapeutic treatment

A patient starting vincristine as part of a lymphoma regimen asks about preventing severe constipation. Which measure is most appropriate?

  1. Routine enemas before each dose
  2. A high-fiber diet alone
  3. Scheduled laxatives and stool softeners Correct answer.
  4. Preemptive vincristine dose reduction

Explanation

Vincristine commonly causes autonomic neuropathy and constipation. A bowel regimen with scheduled laxatives and stool softeners helps prevent severe constipation and ileus.